Safety recommendation SL no 2019/02T

On Wednesday 14 November 2018, the main rotor of LN-OAN struck the spire on a mast in connection with a nearby mast being dismantled and transported away. This resulted in damage to the rotor blades and subsequent emergency landing. The incident would probably have been avoided if the safety margin between the helicopter and the obstacle had been greater. The safe job analysis did not reveal that the "longline" was too short to provide the necessary safety distance.

The Accident Investigation Board Norway recommends that the Civil Aviation Authority, as head of the Aviation Safety Forum for operators of inland helicopters, ensure that the forum continues the effort to improve the operators' methods for risk assessment of operations in general, and the associated safe job analysis for each job in particular. This can increase the likelihood that all aspects of the relevant hazards are identified, including distance to obstacles, and that the outcome is effective.

Safety recommendation SL no 2019/03T

On Wednesday 14 November 2018, the main rotor of LN-OAN struck the spire on a mast in connection with a nearby mast being dismantled and transported away. This resulted in damage to the rotor blades and subsequent emergency landing. The incident would probably have been avoided if the safety margin between the helicopter and the obstacle had been greater. The safe job analysis did not reveal that the "longline" was too short to provide the necessary safety distance. In particular, it is important that the safe job analysis reflect different challenges associated with the relevant mission, and thus used as a safety net and active barrier to adverse events.

The Accident Investigation Board Norway recommends that the Civil Aviation Authority, in its supervisory work, evaluate the safe job analysis to verify that these are adequate for the relevant missions.

Safety recommendation SL no. 2019/01T

On 21 June 2018 OH-HNX, a helicopter from Heliwest hit a crossing power line and cut all three conductors. The risk of collision with crossing lines is very real in connection with helicopter work at low altitude along power lines. This is e.g. illustrated by the fact that, over a six-month period, Agder Energi Nett had three incidents in connection with work along the company's power distribution network. Sweden and Finland have introduced requirements for physical marking of power lines before they are crossed by overhead cables. The AIBN believes such marking could, to a substantial degree, prevent the risk of collision.

The Accident Investigations Board Norway recommends that the Civil Aviation Authority introduce requirements for physical marking of crossing lines in Norway.

Safety recommendation SL No. 2020/03T

The helicopter accident with Mil MI 8AMT RA-22312 in Isfjorden on 26 October 2017 occurred when approaching Heerodden. The AIBN's investigation found that the Convers Avia Airlines JSC organization at “Barentsburg” landing site at Heerodden had developed deviations in relation to the airline's procedures and standards, despite the fact that the base is subject to quarterly internal audits.

The Accident Investigation Board Norway recommends that Convers Avia Airlines JSC conducts a systematic audit of the company’s organization at “Barentsburg” landing site at Heerodden and implements measures to achieve an expected good safety standard.

Safety recommendation SL No. 2020/04T

The helicopter accident with Mil MI 8AMT RA-22312 in Isfjorden on 26 October 2017 occurred when approaching Heerodden. The AIBN's investigation found that the airline’s organization at the “Barentsburg” landing site at Heerodden had developed deviations in relation to the airline's procedures and standards, despite the fact that the base is subject to quarterly internal audits.

The Accident Investigation Board Norway recommends that the State Civilian Aviation Authority – SCAA ensure that Convers Avia Airlines JSC conducts a systematic audit, and defines expected safety standard and implements measures to obtain the expected good safety standard.

Safety recommendation SL No. 2020/05T

The helicopter accident with Mil MI 8AMT RA-22312 in Isfjorden on 26 October 2017 occurred when approaching Heerodden. No one on board used survival suits nor were they wearing life vests. The helicopter was not equipped with liferaft nor emergency floats. Today's national regulations do not set requirements for such emergency equipment for multi-engine helicopters when flying more than 10 minutes from the coastline. For single-engine aircraft, there is a requirement for such equipment when flying more than 3 minutes from the coastline. The AIBN's investigation shows the need for an extension of the existing regulatory requirements to also apply to multi-engine helicopters.

The Accident Investigation Board Norway recommends that the Civil Aviation Authority Norway extend the national regulations so that requirements are set for the use of adequate emergency equipment for all types of helicopters in mountains and desolate areas and on Svalbard. In addition, emergency floats should be used on helicopters when flying over sea irrespective of distance to the coastline on Svalbard.

Safety recommendation SL No. 2020/06T

The helicopter accident with Mil MI 8AMT RA-22312 in Isfjorden on 26 October 2017 near Heerodden, occurred during weather conditions that were reported to be significantly lower than the published weather minima for “Barentsburg” landing site at Heerodden. Convers Avia Airlines JSC allowed only VFR flights on Svalbard. In the demanding weather and at dusk, the pilots lost their visual references and subsequently lost control of the helicopter. Both rapidly changing weather and light conditions are risk factors that indicate the need to be able to fly according to instrument rules. The AIBN sees the need for all helicopter operations that take place during the polar night on Svalbard to be made with helicopters and crews capable of flying according to instrument flight rules.

The Accident Investigation Board Norway recommends the Civil Aviation Authority Norway to extend its regulations to helicopter operations on Svalbard that take place during the polar night to be adapted for instrument flight based for instance on GNSS PinS operations.

Safety recommendation SL No. 2018/16T

19 September 2017, LN-ABF crashed near Hamar airport Stafsberg. The AIBN considers that the simplification in EASA and the national regulations may be negative for aviation safety in some areas. AIBN does not advocate changes in today’s regulations that would result in a reversal of the simplification, but generally considers that a set criteria regarding the contents and duration of familiarization training for new aircraft models in order to assist pilots to fulfil the requirements in EASA OPS Part-NCO.GEN.105 should be enforced. If possible, a qualified flight instructor should be used, but if the pilot chooses to do a self-familiarization on a new aircraft model, the CAA should issue some criteria or requirements as an aid to this familiarization. Such criteria may consist of everything from studying the Pilot Operating Handbook (or equivalent), pre-flight inspection of the aircraft, engine start, taxing, operation of systems on board, take-off and landings in different wind conditions, steep turns, slow flights, stalls and climbs and descents in turns; to emergency procedures and so on. Furthermore the AIBN considers that the CAA with advantage could issue a form or a checklist to be signed subsequent to each item being successfully performed.

The Accident Investigation Board Norway recommends that the Civil Aviation Authority Norway consider whether the current policy, which opens for pilots to do a self-familiarization on new aircraft models within the same class of aircraft without of any documentation of having met a minimum regarding contents and duration, is acceptable from a flight safety point of view.

Safety recommendation SL No. 2018/17T

19 September 2017, LN-ABF crashed near Hamar airport Stafsberg. The Aircraft Flight Manual (AFM) found in LN-ABF was not complete. The few pages that were on board the airplane were only single sheets of paper. The approved flight manual and accompanying documents is the basis in connection with familiarization on new aircraft models and the AFM shall be carried on board during flight. In connection with annual aircraft certification, no routines currently exist to verify that the flight manual is on board .

The Accident Investigation Board Norway recommends the Civil Aviation Authority Norway to consider whether routines should be added to verify that the Aircraft Flight Manual exists on board in connection with annual aircraft certifications.

Safety recommendation SL No 2018/15T

22 August 2017, LN-PTS crashed near Holmestrand. In connection with weighing of aircrafts, it exists a requirement of a new weighing if the empty mass has been changed more than +/- 0,5 % of maximum landing mass and/or CG has been changed more than +/- 0,5 % of MAC. Furthermore, it is normally a requirement to do an assessment of the new values with the values from previous weighing. The Accident Investigation Board Norway (AIBN) consider that a form for empty weight and balance should consist of an assessment of the new values with the values from previous weighing. In this case, the airplane’s empty weight and corresponding center of gravity values were not used to make mass and balance calculations. Several studies suggest that general pilots have a relaxed attitude towards these limitations.

The Accident Investigation Board Norway (AIBN) recommends that the Civil Aviation Authority Norway should provide appropriate “Safety promotion” information. From an airworthiness point of view, measures should be taken to make probability assessments of new values in connection with weighing. Furthermore, information should be provided on the importance of flight operation personnel complying with the limitations announced in the aircraft’s manuals.